Provider Demographics
NPI:1750111886
Name:GOROSPE, TATIANA (MED, EDS)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:GOROSPE
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8112 NEW JERSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-2867
Mailing Address - Country:US
Mailing Address - Phone:239-877-3358
Mailing Address - Fax:
Practice Address - Street 1:8112 NEW JERSEY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-2867
Practice Address - Country:US
Practice Address - Phone:239-877-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25369101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health